Mending broken warriors

PTSD: Combat’s dark legacy — Part 3 of 3

November 12, 2013

In the American Psychiatric Association's 2013 "Diagnostic and Statistical Manual" (DSM-5), post-traumatic stress disorder was changed from an anxiety disorder and moved to a chapter on "Trauma-and-Stress-Related Disorders." According to the APA, "The trigger to PTSD is exposure to actual or threatened death, serious injury or sexual violation." This exposure can occur on the battlefield, as a result of a life-threatening natural disaster, a criminal attack or other traumatic events.

The DSM-5 pays particular attention to four behavioral symptoms that accompany PTSD.

1. Re-experiencing: spontaneous memories of the traumatic event, recurring dreams of the event, flashbacks and other prolonged psychological distress

2. Avoidance: distressing thoughts, feelings and reminders of the event

3. Negative cognitions and moods: a variety of feelings about the event including self-blame or blaming others, estrangement from others, and a diminished interest in normal activities.

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The APA reports some military leaders believe the word "disorder" makes individuals dealing with PTSD symptoms less likely to seek help. These leaders suggest renaming the disorder post-traumatic stress "injury" noting this term is more in line with the language of military personnel and would reduce the stigma of diagnosis.

The growing number of women in the armed forces notwithstanding (14.6 percent as of 2012), the military remains a hyper-masculine organization with even females internalizing the male value of toughness. To have a psychological "disorder" is often interpreted as an individual shortcoming, an internal or inherent weakness of character. To be thought of as such is one of the worst things that can happen to a soldier. The word "injury" does not carry this disapproving meaning as injuries can and do happen to anyone.

The APA rejected changing "disorder" to "injury," stating the military environment needs to change "so that mental health care is more accessible and soldiers are encouraged to seek it in a timely fashion." A military culture more conducive to the psychological needs of combat veterans is crucial to soldiers getting the help they need. Changing "disorder" to "injury" would be an important step in bringing about this cultural shift.

As of June 2010, of the 593,634 Iraq and Afghanistan veterans treated by the VA, 171,423 (28.8 percent) were diagnosed with PTSD. A total of 84,005 veteran-patients were granted VA disability compensation, about half for PTSD. The number of veterans who have PTSD and do not seek treatment is unknown. The relation between PTSD and suicide attempts, and PTSD and completed suicides is also unknown.

Research indicates that certain factors increase the chances military personnel will develop PTSD. These high-risk factors include longer deployment time, more severe combat exposure including seeing others wounded and/or killed, traumatic brain injury, lower rank, lower level of schooling, not being married, being female and being Hispanic.

Because the female combat soldier is a new phenomenon, relatively little is known about the unique issues facing these women. Whereas men with PTSD often report flashbacks, nightmares, irritability and anger, women are more likely to experience depressive symptoms. Retired Army psychiatrist Elspeth Ritchie states that female soldiers are "wanting more than anything else to be like the guys, and so they're not necessarily more likely than the guys to report" PTSD symptoms. A female Army captain in Afghanistan who was having trouble with anxiety and sleeping stated, "I remember feeling ... as a woman being in command, not wanting to fall into the stereotype of, 'We've got another sappy female breaking under pressure.'" She eventually sought help but noted that it wasn't easy.

There are a number of treatment options for PTSD including the following:

Cognitive behavioral therapy: a form of talk therapy with the goal of teaching veterans how to think (or rethink) about war trauma and its aftermath. The therapist helps the individual replace deeply troubling thoughts with less depressing thoughts, as well as to inform the veteran how to cope with feelings of anger, guilt and fear.

Exposure therapy: based on the idea that trauma victims fear thoughts, feelings and situations that remind them of past traumatic events. By talking about traumatic events repeatedly, individuals learn to control or manage these trauma-related thoughts and feelings. While talking about war trauma continually may seem counter-intuitive, the goal is for veterans to feel less overwhelmed about their traumatic experiences over time.

Eye movement desensitization and reprocessing therapy (EMDR): a technique wherein a patient's rapid eye movements under the direction of a therapist reduces the power of emotionally charged memories of past traumatic events.

Medication: helpful in some cases. The VA reports that a category of drugs called "selective serotonin reuptake inhibitors," a type of antidepressant, "appear to be useful, and for some people are very effective." Other medications have been used with some success.

Dr. Belleruth Naparstek, who has worked extensively with PTSD patients, states that prayer and/or ritual can help the healing process. Other helpful techniques or activities include regular physical exercise, meditation, self-hypnosis, practicing relaxation techniques including "conscious breathing" and guided imagery. Naparstek notes that guided imagery can be particularly effective with PTSD patients who struggle to put their feelings into words as they can more easily respond to nonverbal images, symbols and sensations. According to the VA, cognitive-behavioral therapy and EMDR have been the two most effective PTSD treatment modalities. At least one study found that women respond to treatment as well as if not better than men. This may be so because females are generally more comfortable than males talking about their feelings and painful experiences.

To say that retired Army chaplain Eric Olsen of Saranac Lake knows something about PTSD is an understatement. Col. Olsen, who served in Iraq, has counseled hundreds of individuals with PTSD, as well as severely wounded soldiers at Walter Reed National Military Center and the National Naval Medical Center. Olsen cites Pastor Erwin McManus, who believes that for the soul to be content, an individual must have purpose, a sense of belonging and a sense of intimacy. A person can function with two and survive with one, but is in serious trouble if all three are missing. It's not surprising that PTSD symptoms often manifest themselves months after a combat veteran has returned to civilian life and his or her sense of purpose, belonging, and intimacy are being redefined. The former soldier, must, in a sense, create a new self and become part of a civilian world that he or she left years ago. This is no easy task, especially for the veteran whose sense of purpose, content and intimacy are embedded in the military in general, and his or her unit in particular.

Colonel Olsen notes that returning soldiers must ask themselves at least two fundamental questions: "Who are you before God and man? What do you want?" These are hard questions for anyone to answer and can be extremely difficult for combat veterans who have experienced the brutality of war, who were raised with a core "Thou shall not kill" value and then ordered to kill and watch comrades, and often civilians, suffer and die.

When our political leaders send men and women to distant battlefields, they (our leaders) have a long-standing obligation to do whatever is necessary to heal veterans from the psychological horrors of war. If organizations such as Homeward Bound Adirondacks can mitigate war-induced trauma and help restore the emotional well-being of veterans, the time, energy and money required to do so will be well spent. This is especially true of Vietnam, Gulf War, Iraq and Afghanistan veterans who fought in conflicts wherein the burden of multiple-deployment wars was borne by a small percentage of the population and their families.

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George J. Bryjak lives in Bloomingdale, retired after 24 years of teaching sociology at the University of San Diego. He served in Okinawa and Vietnam with the First Marine Air Wing.